Prior Authorizations in Ohio

Ohio Medicaid Clinical Policies

Provider Manuals

Important update for providers:

Effective 1/1/2026, providers must submit medical benefit PA requests through the Availity provider portal, as Molina no longer accepts fax submissions. Continue to follow the current pharmacy submission processes for pharmacy benefit PA requests; do not submit these through the Availity provider portal.

Medical Service Prior Authorizations

Office visits to participating providers and referrals to network specialists do not need PA. Emergency services also do not require authorization.

Molina requires PA for certain services. See which services need PA with the PA Lookup Tool. Providers can request and manage authorizations via the Availity provider portal.

Pharmacy Prior Authorizations

Medicaid

Gainwell, the Single Pharmacy Benefit Manager (SPBM), handles all pharmacy PA for Ohio Medicaid, including prescription drugs. Gainwell uses the Ohio Department of Medicaid’s (ODM) Unified Preferred Drug List (UPDL). All Medicaid managed care plans and Fee-for-Service use the same UPDL.

View the current UPDL: Ohio Medicaid Pharmacy Program

Providers can access the SPBM’s secure provider portal at spbm.medicaid.ohio.gov.  You can find user guides and resources  like the Pharmacy Reference Guide.

SPBM provides coverage for medications dispensed from contracted pharmacy providers. Medications supplied by non-pharmacy providers (such as hospitals, clinics and physician practices) will continue to be covered by Molina or the OhioRISE plan, as applicable.

MyCare Ohio, Medicare and Marketplace

Molina provides appropriate and cost-effective drug therapy to all members covered by the Molina pharmacy program. If a member requires medication that does not appear on the formulary, the physician can make a request for a non-preferred medication.

For more information on pharmacy prior authorization, view your Provider Manual or visit our Ohio provider pharmacy page.